a client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure the nurse tries torefo
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Nursing Elites

NCLEX-PN

Nclex Practice Questions 2024

1. A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:

Correct answer: C

Rationale: The correct answer is 'severe anxiety.' In severe anxiety, a person focuses on small or scattered details and is unable to solve problems. The client's symptoms of rapid speech, trembling hands, tachypnea, tachycardia, elevated blood pressure, feeling nervous, and having trouble sleeping indicate severe anxiety. Mild anxiety enhances the ability to learn and solve problems, while moderate anxiety narrows the perceptual field but allows the client to notice things brought to their attention. During a panic attack, a person is disorganized, hyperactive, or unable to speak or act, which is not the case in this scenario.

2. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?

Correct answer: D

Rationale: Taking corticosteroids in the morning mimics the body's natural release of cortisol, which follows a diurnal pattern with higher levels in the morning. This timing helps regulate the body's inflammatory response and minimizes potential side effects. Answer A is not the primary reason for morning dosing, as adherence concerns can be addressed through other means. Answer B is incorrect since fluid retention is not influenced by the timing of prednisone administration. Answer C is also incorrect as prednisone absorption is not significantly affected by whether it is taken with breakfast or not.

3. A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:

Correct answer: A

Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? It is crucial for pregnant women to avoid alcohol as there is no known safe amount during pregnancy. Consuming any amount of alcohol can harm the developing fetus and increase the risk of fetal alcohol syndrome, a condition characterized by mental and physical abnormalities in infants. Choices B, C, and D are incorrect because they provide misleading information that can potentially harm the fetus. Pregnant women should abstain from alcohol to ensure the health and well-being of their baby.

4. When providing culturally competent care to a couple from the Philippines living in the United States who are expecting their first child, what should the nurse do first?

Correct answer: A

Rationale: When providing culturally competent care, the nurse's initial step is to reflect on and understand their own cultural beliefs and biases. By doing so, the nurse can approach the care of the couple from the Philippines with sensitivity and respect. This self-awareness helps the nurse recognize potential differences in beliefs and values, fostering effective communication and care. Option B is incorrect because it does not address the nurse's need for self-reflection. Option C is incorrect as it focuses on the clients adapting to the new country's practices rather than the nurse understanding the clients' existing beliefs. Option D is incorrect as it pertains to family dynamics and gender roles rather than the nurse's self-awareness.

5. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Correct answer: C

Rationale: The most crucial assessment during the preoperative period for a client scheduled for surgical repair of a sacular abdominal aortic aneurysm is the identification of peripheral pulses. This is essential because during surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Monitoring peripheral pulses helps assess circulation to the lower extremities, ensuring adequate perfusion. While assessing the client's anxiety level (choice A) is important, it is not as critical as monitoring peripheral pulses in this case. Evaluating exercise tolerance (choice B) is not typically recommended preoperatively for this specific condition. Assessing bowel sounds and activity (choice D) is also relevant but takes a lower priority compared to identifying peripheral pulses in this scenario.

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